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Melanoma Extirpation with Immediate Reconstruction: The Oncologic Safety and Cost Savings of Single-Stage Treatment

Duquette, Stephen P. M.D.; Wooden, William M.D.; Coleman, John M.D.; Tholpady, Sunil M.D., Ph.D.

Plastic and Reconstructive Surgery: March 2017 - Volume 139 - Issue 3 - p 796e–797e
doi: 10.1097/PRS.0000000000003091
Letters

Department of Surgery, Division of Plastic Surgery, Indiana University School of Medicine

Department of Surgery, Division of Plastic Surgery, Indiana University School of Medicine, Division of Plastic Surgery, Roudebush VA Medical Center

Department of Surgery, Division of Plastic Surgery, Indiana University School of Medicine

Department of Surgery, Division of Plastic Surgery, Indiana University School of Medicine, Division of Plastic Surgery, Roudebush VA Medical Center, Indianapolis, Ind.

Correspondence to Dr. Tholpady, Indiana University School of Medicine, Roudebush VA Medical Center, 705 Riley Hospital Drive, RI 2514, Indianapolis, Ind. 46202, stholpad@iupui.edu

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Sir:

In the article entitled “Melanoma Extirpation with Immediate Reconstruction: The Oncologic Safety and Cost Savings of Single-Stage Treatment” by Karanetz et al.,1 the authors discuss the safety and cost savings of reconstructing melanoma resections in a single stage. This method clearly provides potential cost savings to the system and is more convenient for the patient. However, melanoma is an increasing source of morbidity and mortality in the United States, with 76,690 individuals diagnosed with malignant melanoma, accounting for 9480 deaths in 2013, and with the incidence of melanoma rising faster than that for most other solid malignancies.2 Safety, measured in morbidity, 5-year disease-free recurrence, and 5-year overall survival are of the most importance.

The authors discuss their positive margin rate and actual margins at the time of initial resection. The positive margin rate in this particular series was nine of 534 patients (1.68 percent). This is low compared with a larger series, as Dhepnorrarat et al. had a positive margin rate of 4.73 percent in malignant melanoma resections in 1459 patients.3 Also unclear from the article is the cost of a potentially more extensive reconstruction after reconstruction has been completed at the initial stage and is subsequently found to have a positive margin on final pathologic evaluation. In addition, the potential clinical complications of these positive margins that have already been covered with a flap are unclear, as monitoring for locoregional recurrence may become more difficult. The margins in Table 1 appear to be below the suggested National Comprehensive Cancer Network guidelines for T3 and T4 lesions, and should be at least 2 cm by current guidelines.4

The mean follow-up in this study is 1.2 years, whereas the majority of the surgical oncology literature includes follow-up up to 5 years for recurrence, disease-free intervals, and overall survival. The National Comprehensive Cancer Network guidelines on melanoma review several studies regarding recurrence. In a retrospective study of patients who initially presented with stage I melanoma (n = 1568), 80 percent of the 293 recurrences developed within the first 3 years, but some recurrences (<8 percent) were detected 5 to 10 years after the initial treatment, and a prospective study found that for patients with stage I or II at initial presentation, the risk of recurrence reached a low level by 4.4 years after initial diagnosis.4

In our practice over the past year, approximately 121 melanoma patients have been treated with immediate reconstruction with either primary closure or skin grafting. This is similar to the authors’ treatment except we do not perform adjacent tissue rearrangements because we believe that this is oncologically unsound, as the entire wound bed is potentially contaminated with a positive margin. We have not had to perform any revisions for aesthetic purposes and have had two positive margins that were easily excised.

Although we applaud the authors’ study with single-stage melanoma resection and reconstruction and the cost savings associated with it, we feel it is important to continue to adhere to oncologic principles and complete margin evaluation before more extensive reconstruction such as adjacent tissue rearrangements, which account for 30 percent of the authors’ practice. We believe that primary closure and skin grafting continue to be the standard for primary melanoma extirpation and wound closure. Further follow-up should be required to fully assess the safety of these single-stage resections with adjacent tissue rearrangements.5

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DISCLOSURE

The authors have no financial disclosures or conflicts of interest related to this communication.

Stephen P. Duquette, M.D.

Department of Surgery

Division of Plastic Surgery

Indiana University School of Medicine

William Wooden, M.D.

Department of Surgery

Division of Plastic Surgery

Indiana University School of Medicine

Division of Plastic Surgery

Roudebush VA Medical Center

John Coleman, M.D.

Department of Surgery

Division of Plastic Surgery

Indiana University School of Medicine

Sunil Tholpady, M.D., Ph.D.

Department of Surgery

Division of Plastic Surgery

Indiana University School of Medicine

Division of Plastic Surgery

Roudebush VA Medical Center

Indianapolis, Ind.

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REFERENCES

1. Karanetz I, Stanley S, Knobel D, et alMelanoma extirpation with immediate reconstruction: The oncologic safety and cost savings of single-stage treatment.Plast Reconstr Surg2016138256–261
2. Khan SA, Bank J, Song DH, Choi EABrunicardi F, Andersen DK, Billiar TR, et alThe skin and subcutaneous tissue.In: Schwartz’s Principles of Surgery201410th edNew YorkMcGraw-HillAvailable at: http://accesssurgery.mhmedical.com.proxy.medlib.uits.iu.edu/content.aspx?bookid=980&Sectionid=59610858. Accessed July 17, 2016
3. Dhepnorrarat RC, Lee MA, Mountain JAIncompletely excised skin cancer rates: A prospective study of 31,731 skin cancer excisions by the Western Australian Society of Plastic Surgeons.J Plast Reconstr Aesthet Surg2009621281–1285
4. National Comprehensive Cancer NetworkMelanoma (Version 3.2016).Available at: https://www.nccn.org/professionals/physician_gls/pdf/melanoma_blocks.pdf. Accessed July 17, 2016
5. Behan FC, Rozen WM, Kwee MM, Kapila S, Fairbank S, Findlay MWOncologic clearance with preservation of reconstructive options: Literature review and the ‘delayed reconstruction after pathology evaluation (DRAPE)’ technique.ANZ J Surg201282780–785
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